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- Dermatitis -
6/14/05 re: Referral for scaling rash
I am an LCPC working with a foster child recently removed from her home. She is being treated with hydrocordizone cream, only when a patch 'itches'. She has acetometophen and codine (suspension) for pain. Her mouth is drawn in from the sides due to the dryness. Her entire body is scaly and has spots of scabs all over. She said her feet hurt her when she walks because they crack. What can the foster mother do to relieve this child and what kind of specialist should she see? She has a history of peanut and soy allergy but no milk or egg allergy is reported.
The differential diagnosis based on the limited information you provided is fairly broad, particularly if the foster child came from a previous sub-optimal environment where a primary or secondary skin infection could be playing a role. My first choice for someone to evaluate the child would be a dermatologist with an extensive experience in childhood skin diseases. Such physicians are often associated with a children's hospital in large metropolitan areas. You did not mention your geographic location so I cannot specify more than that.
Until such an evaluation can be carried out, one could try measures to decrease excessive dryness in the involved skin areas. These include: 1) avoid excess bathing (particularly in very hot water) and use of drying and scented soaps. Use of a soap-less skin cleanser such as Cetaphil is preferable; 2) when the tepid water bath/shower is completed, pat the skin dry without excess rubbing. Apply an emollient cream such as aquaphor-containing cream to the affected areas and rub in gently. One has to be careful about excessive, chronic use of topical steroid creams or ointments such as hydrocortisone because it may lead to local side-effects; 3) avoid foods strongly suspected of flaring the skin problems until further investigation can be carried out.
6/1/05 re: Rash after ocean swimming
I am a registered Nurse and my husband is a pharmacist. Over the past couple of years our travels have taken us to the Hawaii (my husband has grown up swimming in Hawaii) and to the beaches of North Carolina. We have also taken other vacations where we have swum in private swimming pools. Both in Hawaii and North Carolina my husband (31 years old) has developed a rash after swimming in the ocean. It starts out as little circular gathers of almost a blister like rash on his arms (kind of reminds us of poison ivy). Then the rash spreads to large bumps all over his shoulders, upper back and arms. It itches him and looks bad. He has taken benadryl, applied lotions, and steroid creams but nothing seems to work. Do you think he might be allergic to salt water, at times he wears sun block could that be it? It doesn't happen with plain sun exposure or swimming in hot tub or pools. He's also not on any medication.
The possible cause of the rash you mentioned (photosensitivity in areas of sunblock application) can be investigated by determining whether the rash occurs when your husband applies the same sunblock with following sun exposure but no ocean swimming at that time. I also assume from your lack of mentioning it that he has not been taking any systemic medication (such as doxycycline) to which some individuals manifest a photosensitivity reaction when exposed to the sun. If the rash occurs during rapid drying of the skin after emerging from the ocean, it could be aquagenic urticaria. However, the rash you described does not sound like urticaria. Also, one would expect a similar rash to occur when drying off from swimming in pools, lakes, etc.I think that an allergy to salt water itself is extremely unlikely. However, I think that your husband's problem may be "sea bathers eruption" since he does not manifest the same rash after swimming in swimming pools. I have enclosed my response to a somewhat similar previous Ask the Expert question. My discussion in that response describes this disorder. It should be noted that not every one swimming in ocean water at the same time will manifest this rash. But it would be surprising if your husband were the only one involved. Also, the skin areas around and under the bathing suit may be particularly involved.
Previous Ask the Expert response:
I assume from your lack of mentioning it that the patient in question does not exhibit a rash after swimming in equally cold lake water (or cold swimming pool water if that has been experienced).If so, then the possibility of "seabather's eruption" can be raised (see enclosed abstracts). As noted in these abstracts, this eruption has been reported mainly from "warm ocean" areas although occasional mini-epidemics occur in more northern latitudes such as Long Island, NY. As you can see, the rash is mainly pruritic papules although urticaria has also been reported. It would be worth exploring whether there were other cases of rash in individuals swimming in that part of the ocean at the same time. Another possibility is a contact urticaria due to contact with certain "algae blooms". The dino flagellate-induced rash is generally accompanied by systemic symptoms.Of course, other possible factors may be considered: 1) does the patient use any medication (systemic or topical) when in ocean but not fresh water swimming (e.g., sunscreen) that may be sunlight-activated (photo-allergic reaction)? 2) Is the rash related to the temperature of the water? 3) Does the rash occur if the patient just immerses herself briefly in the ocean water, then goes out onto the shore to dry off spontaneously.? If the rash worsens during the drying off stage, consider something analogous to aquagenic urticaria.
J Am Acad Dermatol. 1994 Mar;30(3):399-406.
Seabather's eruption. Clinical, histologic, and immunologic features.
Wong DE, Meinking TL, Rosen LB, Taplin D, Hogan DJ, Burnett JW. Department of Dermatology and Cutaneous Surgery, University of Miami, FL 33101.BACKGROUND: Seabather's eruption (SE) is a highly pruritic eruption under swimwear that occurs after bathing in the ocean. Its cause has been unknown. Few data have been collected since the classic description by Sams in 1949. OBJECTIVE: Our purpose was to describe the clinical and histopathologic findings in SE and to confirm the cause.
METHODS: Patients with a pruritic eruption that developed after swimming were seen within 1 week of onset. Skin biopsy specimens and sera were obtained in selected cases. Water samples taken from areas of active SE outbreaks were examined for a causative organism. Sera were tested by enzyme-linked immunosorbent assay for reactivity to this organism.
RESULTS: In southeast Florida, during a 4-month period, 70 patients with SE were seen. Inflammatory papules and pruritus were noted within hours of exposure. Eruptions were maximal in areas covered by a bathing suit. Children were more likely than adults to have systemic symptoms. The average duration of the eruption and pruritus was 12.5 days, with recurrences in 4.3% of patients. Histopathologic examination revealed a superficial and deep perivascular and interstitial infiltrate consisting of lymphocytes, neutrophils, and eosinophils. Water samples contained many cnidarian larvae, later grown to maturity and identified as Linuche unguiculata (thimble jellyfish). Enzyme-linked immunosorbent assay demonstrated in patients' sera high IgG levels specific for L. unguiculata.
CONCLUSION: SE is a severely pruritic marine dermatosis that resolves spontaneously within 2 weeks. Therapy is symptomatic but often ineffective. Sera from affected persons showed specific reactivity to L. unguiculata.
South Med J. 1995 Nov;88(11):1163-5.
Seabather's eruption.
Ubillos SS, Vuong D, Sinnott JT, Sakalosky PE .
Division of Infectious Diseases and Tropical Medicine, University of South Florida College of Medicine, Tampa, USA.
Seabather's eruption is an unusual rash that develops in individuals who have been swimming in the ocean. We report the case of a 25-year-old woman who had the rash in a typical bathing suit distribution. Several species of cnidarian larvae have been implicated in causing the disease. Symptomatic treatment is the mainstay of therapy for this self-limited rash. Preventive measures allow patients to avoid the disease altogether
N Engl J Med. 1993 Aug 19;329(8):542-4. Related Articles, Links
Seabather's eruption.
Freudenthal AR , Joseph PR.
Office of Marine Ecology, Nassau County Department of Health, Mineola, N.Y.BACKGROUND. Seabather's eruption is an annoying pruritic dermatitis that appears on the areas covered by the bathing suit as an erythematous macular or papular dermatitis, with or without urticaria. It occurs sporadically in Florida the Caribbean, and as far north as Bermuda . The cause is not known. METHODS. We collected information in Nassau County, Long Island, New York, about cases of all types of water-related dermatitis reported by beach personnel, health providers, and affected swimmers from 1970 through 1991. Concurrently, we surveyed all Nassau County swimming waters, especially during the summer season (June through September), for the presence of organisms capable of causing dermatitis. In 1980 a sudden epidemic of a severe, unfamiliar dermatitis in ocean bathers prompted increased surveillance of cases and waters. Planula larvae of the phylum Cnidaria were collected from the ocean and beaches and inside bathing suits. They were examined, photographed, tested on healthy subjects, and observed in the laboratory for metamorphosis.
RESULTS. Three outbreaks of seabather's eruption have occurred on Long Island since 1975. The first, in August 1975, affected a small number of swimmers on the eastern end of Long Island. In 1980 there were thousands of cases along the entire south shore of the island, and in 1990 there were hundreds in the same area. In nonepidemic years, five or fewer cases have been reported yearly. Surveillance for larvae revealed them to be present during the swimming season in epidemic years, but in nonepidemic years they did not appear until autumn, after the swimming season. Applying larvae to the skin of healthy subjects produced a dermatitis indistinguishable from seabather's eruption. All larvae metamorphosed in the laboratory to the adult sea anemone Edwardsiella lineata. CONCLUSIONS. Seabather's eruption, previously reported only as sporadic cases in southern climates, has occurred sporadically and in outbreaks 1000 miles north of most previously described cases. These Long Island episodes were probably caused by the planula larvae of E. lineata. Public Health Rep. 1997 Jan-Feb;112(1):59-62.
Risk factors for seabather's eruption: a prospective cohort study.
Kumar S, Hlady WG, Malecki JM.
Division of Epidemiology and Disease Control, Palm Beach County Public Health Department, Riviera Beach , FL 33404, USA.OBJECTIVE: A prospective cohort study was performed to identify risk factors for seabather's eruption. METHODS: Study participants were recruited at four beaches in Palm Beach County , Florida , during three weekends of May and June 1993. Participants were interviewed by telephone after 48 hours regarding medical history, beach activities, development of rashes, and use of possible preventive measures. RESULTS: Seabather's eruption, defined by the occurrence of a rash within two days of exposure to seawater, was reported by 114 (16%) of 735 respondents. The strongest predictor of seabather's eruption was a past history of the condition. Children less than 16 years of age were also at increased risk, as were surfers. Showering with one's bathing suit off was a useful protective measure. CONCLUSION: The study's findings suggest that when the seasonal risk of seabather's eruption is present, children, people with a history of seabather's eruption, and surfers are at greatest risk. During the sea lice season, seabathers can minimize their risk by showering with their bathing suits off after seabathing. Length of the time spent in water was not significantly associated with seabather's eruption
5/3/05 re: Cause of itchy rash
Both my husband and I are pharmacists, my husband is a nuclear pharmacist who expose radiation daily base, his exposure level is within goverment guideline, he has suddenly developed abormal rash since last august, he also becomes diabetic last year too, we have seen 2 dermatolgy and immunolgy, we cannot figure what's wrong with him, currently he takes actos, ambien to sleep, all doxepin, prednisone does not help, he starts out red patch on his waist line and now he spreads all over his arm and head, he trys prednisone in tape off dose, once the steroid ware off, the rash comes back, the immunolgy thinks it is nerve rash due to diabetic and stress, but I am concern could it be other severe problem.
It is very difficult to suggest causes for a rash when one has not observed the rash oneself on at least one occasion. However, I will give you some thoughts and suggestions:
1) You did not mention whether the rash was scaly or not. If the rash is scaly, particularly in a diabetic, one should rule out a superficial fungus infection by appropriate studies of scrapings of a fresh skin lesion.
2) When I hear that an itchy rash started with an isolated patch in one area, then followed by a more extensive rash in other areas, particularly when in a linear distribution, I think of pityriasis rosea. This type of rash may improve while receiving prednisone therapy. An experienced dermatologist should be consulted about this possibility.
3) If the rash is very itchy, consider dermatitis herpetiformis. This can be diagnosed by a biopsy of a reasonable fresh lesion for both standard dermatopathology and immunofluorescence studies (looking for IgA deposition).
4) If there is any blistering in an itchy rash in an older man, consider bullous pemphigoid. A skin biopsy/immunofluorescence study should help to diagnose this.
There are other possibilities, of course, but the ones above come first to my mind.
Although it sounds from your message that the rash is improved by prednisone therapy, such treatment should be kept at the lowest dose and the shortest duration feasible since prednisone therapy frequently makes diabetes more difficult to control.
4/6/05 re: Salt water eruption
A 55 y/o female presented with a 23 yr history of developing a pruritic rash around her joints - ankles, knees, elbows - within 1-2 hours of contact with saltwater. She experiences no rash with freshwater, nor does she have any other physical urticaria by history. Her rash is not related to where her swimsuit is in contact with her skin. She has a history of migraine headache and mild depression, both well-controlled with medication. Her rash responds to Benadryl, topical steroid creams, and very well to low-dose oral Medrol. Her rash does not respond to Allegra or Zyrtec. Her sister has a history consistent with aquagenic urticaria. My own literature search of saltwater urticaria did not describe this patient. Has this type of what I presume is a physical urticaria been reported before? You did not mention: 1) at what ocean latitutde your patient experienced the rash. Does it occur at relatively northern latitudes or just in the southern latitudes? 2) do other individuals experience the rash during exposure to the same ocean water?; 3) if salt water solution prepared at home (to simulate the salt concentration of ocean water) is applied for 30 minutes or so to the skin, are symptoms triggered?
As you likely know, a disorder, sometimes called "swimmer's itch" has been reported periodically in those exposed to ocean water in some regions (mainly in the Caribbean area, although "epidemics" of such have been found in Long Island ocean swimmers (see enclosed abstract). This rash has been attributed to reactions to planula larvae of the phylum Cnidaria. It is true that this rash tends to be concentrated in skin under bathing suits (apparently not the case in your patient). It would be unusual to have such a rash occur in just your patient and not in others swimming in the same place.A more multi-organ disorder has been the Pfiesteria- human illness syndrome, thought due to reactions to a dinoflagellate in the Maryland saltwater area (see enclosed abstract).
Of course, other possible factors may be considered: 1)does the patient use any medication (systemic or topical) when in ocean but not fresh water swimming (e.g.-sunscreen) that may be sunlight-activated (photo-allergic reaction)? 2) Is the rash related to the temperature of the water? 3) Does the rash occur if the patient just immerses herself briefly in the ocean water, then goes out onto the shore to dry off spontaneously.? You mentioned aquagenic urticaria.
A simple and possibly helpful "experiment" could be to have the patient cover the left side of her exposed skin with a liberal coating of petrolatum jelly, leaving the right side exposed right before entering the ocean water. After the usual duration of water exposure which previously induced symptoms, she goes ashore and sees whether there is a different occurrence of rash in the two sides of the body. If there is, remove the petrolatum jelly coating with some ocean water and observe for another 1-2 hours.
N Engl J Med. 1993 Aug 19;329(8):542-4.
Seabather's eruption.
Freudenthal AR , Joseph PR.
Office of Marine Ecology, Nassau County Department of Health, Mineola, N.Y.BACKGROUND. Seabather's eruption is an annoying pruritic dermatitis that appears on the areas covered by the bathing suit as an erythematous macular or popular dermatitis, with or without urticaria. It occurs sporadically in Florida , the Caribbean, and as far north as Bermuda. The cause is not known. METHODS. We collected information in Nassau County, Long Island, New York, about cases of all types of water-related dermatitis reported by beach personnel, health providers, and affected swimmers from 1970 through 1991. Concurrently, we surveyed all Nassau County swimming waters, especially during the summer season (June through September), for the presence of organisms capable of causing dermatitis. In 1980 a sudden epidemic of a severe, unfamiliar dermatitis in ocean bathers prompted increased surveillance of cases and waters. Planula larvae of the phylum Cnidaria were collected from the ocean and beaches and inside bathing suits. They were examined, photographed, tested on healthy subjects, and observed in the laboratory for metamorphosis.
RESULTS. Three outbreaks of seabather's eruption have occurred on Long Island since 1975. The first, in August 1975, affected a small number of swimmers on the eastern end of Long Island . In 1980 there were thousands of cases along the entire south shore of the island, and in 1990 there were hundreds in the same area. In nonepidemic years, five or fewer cases have been reported yearly. Surveillance for larvae revealed them to be present during the swimming season in epidemic years, but in nonepidemic years they did not appear until autumn, after the swimming season. Applying larvae to the skin of healthy subjects produced a dermatitis indistinguishable from seabather's eruption. All larvae metamorphosed in the laboratory to the adult sea anemone Edwardsiella lineata.
CONCLUSIONS. Seabather's eruption, previously reported only as sporadic cases in southern climates, has occurred sporadically and in outbreaks 1000 miles north of most previously described cases. These Long Island episodes were probably caused by the planula larvae of E. lineata.
Md Med J. 1998 Feb-Mar;47(2):64-6. Related Articles, Links
Treatment of persistent Pfiesteria-human illness syndrome.
Shoemaker R.Patients with exposure to Pfiesteria toxin have developed an illness, Pfiesteria- human illness syndrome, characterized by skin lesions, headache, myalgias, conjunctival irritation, bronchospasm, abdominal pain, secretory diarrhea, recent memory loss, and difficulties with number sequencing. Not all patients demonstrated all features of the syndrome. The natural history of Pfiesteria- human illness syndrome shows that most patients' symptoms improve without treatment. This article reports the improvement of symptoms that had persisted for over one month in five patients, which the author attributes to treatment with cholestyramine. These patients were self-referred to the Pocomoke River Rash and Associated Illness Center, a clinic that opened on August 6, 1997, in response to the need for a central facility for diagnosis of human illness acquired from Pfiesteria. Until the Pfiesteria toxin(s) is isolated and characterized, and laboratory diagnostic tests are available, physicians must be able to recognize Pfiesteria-human illness syndrome and intervene when symptoms, particularly memory loss and diarrhea, cause significant impairment in daily activities. There are no precedents for the reatment of Pfiesteria or any dinoflagellate toxin-related human illness reported in the literature. The successful use of cholestyramine reported here may provide a model for understanding dinoflagellate toxin physiology in the human body. This paper reports an uncontrolled observational study. When identification of the toxin is completed, a basis for properly controlled studies will be available.
1/26/04 re: Cause of pruritic rash with dry skin
I am a Clinical Psychologist. I am working with a 63 year old man with no hx of eczema, asthma, or allergies. Past and recent physicals and complete blood panels normal. Some elevation of LDL and triglycerides. Hx of mono (age 50) followed by CFIDS. CFIDS onset was accompanied by dramatically increased thirst. With episodes of exacerbated fatigue, skin on right hand dried and peeled. About 1 year ago he developed intermittent pruritis of the crural folds. Saw physician who observed nothing and recommended Ketoconazole. Pruritis spread to scrotum and pubis, perineum, and sacrolumbar areas followed by dyshidrosis of left and right chest (papules, pruritis, lichenification: now largely gone). Volar hands became itchy, dry, scaly with some weeping vesicles at webbing. Went from internist, to dermatologist, to allergist (extensive patch testing negative).
Current:
Pruritis--areas of scalp, lichenifications and excoriations of thighs and ankles. Hands appear normal, but dry easily and are subject to cracking at webbing. Groin (as above) and hands are focal areas with worsening at night. Awakens in early AM with crural and/or pubic pruritis. He complains that his hands feel as if the epidermis is dry, although he has tried various skin moisturizers and Elidel. Already coping with depression over other factors and taking Lexipro (20mg), this is worsening his mood, disrupting his concentration and causing angry outbursts.
My question is whether this is eczema or could it be another systematic problem? Recent diabetes testing was negative. I observed the dryness of his fingers two years ago, before pruritic onset. Now entire hands have dry appearance unless he uses moisturizer. It seems that there is a general physiological drying that has not been considered by his physicians. I am open to any suggestions, as this is aggravating his mental state.You have described a somewhat atypical clinical picture in which there appears to be a broad differential diagnosis. When I have seen prominent itching in a 63 year old man, I have approached the diagnostic possibilities divided into two categories:
1. Is this a primary skin problem with secondary itching?
One condition which must be considered is mycosis fungoides, a type of skin lymphoma. This can present at times with an eczematous rash, often quite pruritic. A biopsy of a skin lesion, processed and examined by an experienced dermatopathologist is essential to consider this diagnosis.
The prominence of itching and rash in the folds, public area and hands raises the possibility of a parasitic infestation, particularly scabies or pediculosis pubis. Such parasitic infestations are not always limited to those in the lower socio-economic strata. Appropriate scraping/biopsy studies will explore this possibility. Also, I assume from your comments that a differential leukocyte count was done and was normal. If not done (and maybe repeat even if done) looking for peripheral blood eosinophila (elevated levels suggest m. fungoides or parasitic infestation). Candida infection is less likely, in my opinion, but can be investigated by special stains of a skin biopsy.
2. Is this a systemic condition manifest as pruritis with secondary skin manifestations?
It is not unusual for the scratching of the skin in someone with prominent chronic pruritis to lead to secondary occurrence of skin lesions, including papules and scaling. Some of the systemic conditions to be considered are:
Diabetes - although fasting blood sugars may be normal, obtain 2 hour post-prandial blood sugar.
Biliary obstruction - (e.g., idiopathic biliary cirrhosis)- obtain liver function tests, particularly directed to obstructive diseases. If abnormal, obtain anti-mitochondrial antibody tests, ultrasound studies for extrahepatic obstruction.
Chronic renal insufficiency - Should have other manifestations as well. However, check serum creatinine.
Systemic dyshidrosis - This can be checked by the response to an injection pf pilocarpine to see if normal sweat gland response. Also check whether excess dryness in the oral cavity, eyes. If these mucosal surfaces also very dry, suggests an anti-cholinergic effect, drug-induced or otherwise.
I am not aware of evidence that prominent pruritis is a common manifestation of idiopathic or (postulated) EBV- related chronic fatigue syndromes (CFS). As you likely know, some groups have reported an autonomic nervous system abnormality in some individuals meeting the CDC diagnostic criteria for CFS. It is conceivable that a result of such an abnormality could be excessive skin dryness.
With regard to therapeutic trials for the pruritis, one can try topical doxepin cream (Zonalon) on affected areas. If this is not helpful, consider use of a moisturizing cream containing a local anesthetic such as lidocaine for skin areas of severe pruritis (Neutrogena makes such an over the counter product in their "Norwegian. Formula" group, called Anti-itch Moisturizer. Make sure that the product chosen contains lidocaine since there are other products in the "Norwegian. Formula" group.) The patient should be told that occasionally individuals develop a contact sensitivity to the lidocaine with prolonged use.
12/19/02 re: Severe contact dermatitis
Can you please suggest treatment to patient with reaction to mortar mix, blistered sores entire body, continues to spread with severe itching. Although I have not seen this patient or pictures of the lesions, your description suggests a severe contact dermatitis. In such situations, my usual approach has been:
1) A course of daily oral steroids unless there is an absolute contraindication. I would start with about 60 mg prednisone/day for an average sized adult and then taper the dose to zero over the succeeding 2 weeks, decreasing the dose every other day. If there are residual areas of rash after 2 weeks, these can generally be cleared with a reasonably potent topical steroid.
2) Prevention of secondary infection in involved skin areas. This is very important when there is significant blistering and scratching by the patient. Gentle cleansing of the skin with an antiseptic soap solution in a bathtub should do it. The patient should be instructed to keep the nails cut short and hands washed frequently with antiseptic soap to reduce chances of infecting the skin during scratching If there appear to be already secondarily infected areas, a topical broad spectrum anti-bacterial ointment may be necessary. When the patient gets out the bath, the excess water remaining on the skin should be patted (not rubbed) off gently, leaving the skin damp and a lubricating cream then applied. If itching is severe, one may consider use of one of the thicker lubricating creams that also contain lidocaine. Neutrogena is one of the companies that makes such a cream (called Smoother Release anti-itch Moisturizer) but check the label to be sure it contains lidocaine (they make several moisturizers which are packaged in similar looking containers).
3) If itching is not controlled by the above approach, one can also use an antihistamine with variable efficacy. For generalized itching, an orally administered antihistamine is preferred. Diphenhydramine (Benadryl), 50 mg or doxepin 50 mg are probably more potent in this regard but can be sedating or interfere with reflexes when driving, etc. The more recent non-sedating antihistamines (e.g., fexofenadine, Allegra) can be tried if sedation must be avoided. Doxepin cream (Zonalon) may be helpful for topical treatment of a few isolated very itchy areas.
9/6/01 re: Contact dermatitis from oleander?
I have recently come in contact with (allergic) dermatitis caused by oleander but I could not find anything about other similar cases or about relative aptens. As you likely know, ingestion of several parts of the oleander plant (particularly the yellow oleander) can be quite toxic, due to adverse effects on the heart from a glycoside, similar to that found in the digitalis plant. However, in a Medline search, I could find only one reference to a contact dermatitis attributed to oleander. This brief report (Oleander dermatitis. Contact Dermatitis. 1983 Jul; 9(4): 321.) is in an issue not stored in our Biomedical Library. Therefore, I cannot determine how the authors confirmed this diagnosis. However, based on some other information, I would wonder whether the responsible allergen in oleander might be the glycoside similar to that in digitalis. 6/5/01 re: Rash appearing each spring
47 yo woman, with 7 consecutive seasons of dermatitis. Onset late April or early May (northern New York state location). Typically blotchy on neck, then involves antecubital areas, and inner thighs. will expand over 4 weeks to involve 50% volar surface arms, spotty on neck and face, confluent on inner thighs. This year for 1st time blister on r inner arm. Very pruritic. Occurs prior to outdoor spring activities and purposely refrains from gardening or similar activities to reduce possibility of plant dermatitis. Had exposure to tomato plant (hands) 24 prior to onset this year, but not in prior years. Progress despite high potency topical steroids, and gradually improves with 80mg prednisone orally. Duration 5-6weeks. Biopsy done elsewhere: "nonspecific dermatitis." As this only occurs in the tree pollen season I speculate a relationship. Any thoughts? Plan is to perform skin testing. consideration to adding tacrolimus topical next season when it recurs.
I assume from your description that your patient's rash that appears each spring is related to her spending more time outdoors at that time and that the involved areas of skin are those exposed to the sunlight. If so, the first diagnostic possibility that comes to my mind is the polymorphic light eruption (PLE) This disorder is characterized by recurrences when individuals first spend more time in the outdoor sunlight (typically in the spring) and usually lasting about 6-8 weeks (see enclosed abstract). As indicated by the name, the lesions of PLE can be of several different appearances although papulovesicular lesions are the most common type. The blistering that your patient exhibited this year could be compatible with that pattern. There are no histopathologic changes specific for PLE in biopsies of skin lesions (see enclosed abstract). The diagnosis can be confirmed to a degree by a dermatologist doing a U.V. light challenge of uninvolved (non-exposed) skin. Other light-activated reactions (phototoxic, photoallergic, subset of porphyrias) can be considered but are unlikely because you described your patient's rash clearing after 5-6 weeks despite continued exposure to sunlight. The "blistering" diseases (e.g. pemphigus) would be very unlikely to remit after 5-6 weeks when off therapy. I think it unlikely that tree pollen is the cause of the rash. Certainly, contact dermatitis can be induced by direct contact of certain pollens to the skin. However, I think it very unlikely that the exposure to pollens floating in the air would induce such reactions, particularly without pronounced symptoms of allergic reactions in the upper airway. eyes and possibly lower airways. I know of no trials of topical tacrolimus for an eruption such as you describe.
Photodermatol 1989 Apr;6(2):69-79
Polymorphous light eruption: successful reproduction of skin lesions, including papulovesicular light eruption, with ultraviolet B.
Miyamoto C.
Department of Dermatology, School of Medicine, Tokyo Medical and Dental University, Japan.Thirty patients suffering from polymorphous light eruption (PLE), selected by criteria pointing to UVB sensitivity, were phototested for reproduction of skin lesions. Twenty-seven patients (90.0%) had symptoms compatible with or very similar to papulovesicular light eruption (PVLE). Of the 30 patients, 56.7% developed typical lesion of PLE at the test site by provocative phototesting with UVB. Eruptions of the immediate onset type were apt to be reproduced by multiple repeated irradiation, but those of the delayed onset type were reproduced by a single high-dose exposure. In addition, pruritus at the test site seen in all patients was thought to be an important diagnostic symptom. It was obvious that UVB played an etiological role in PLE, including PVLE.
J Cutan Pathol 1986 Feb;13(1):13-21
Histopathologic findings in papulovesicular light eruption.
Hood AF, Elpern DJ, Morison WL.Papulovesicular light eruption (PVLE) is a distinct clinical and histological subset of polymorphous light eruption. Biopsies from 16 patients with PVLE showed prominent epidermal and dermal changes consisting of intercellular edema, papillary dermal edema and a perivascular and interstitial infiltrate in the upper dermis.
5/7/01 re: Facial rash in a small child
Nine-year-old boy with itchy, maculopapuar rash only around eyes, more prominent in summer. Has mild allergic rhinitis and also in the summer gets slightly hypopigmented areas on his face and exposed areas (his parents are of Indian origin).
Because I have not been involved in the care of small children for many years, I consulted Dr. Susan Schuval, a very experienced Pediatric Allergist and a member of our AADMC Advisory Committee. Her response is enclosed below.
The differential diagnosis for this patient includes:
Seasonal allergic rhinoconjunctivitis: Patient should have accompanying symptoms of conjunctival erythema, tearing, possible eye discharge, and ocular pruritus. Treatment would consist of topical antihistamines and/or mast cell stabilizers (cromolyn, ketotifen) with use of a systemic antihistamine (loratidine, cetirizine) if relief is not obtained.
Eyelid eczema: Patient should have atopic dermatitis affecting other areas of the body. Conjunctiva would be unaffected. Treatment would consist of very cautious application of low potency topical steroids +/- systemic antihistamine.
Pollen allergy: In very atopic individuals, such a rash may be secondary to contact of the skin with pollen grains. Treatment would consist of standard pollen avoidance measures and systemic antihistamines.
5/07/01 re: Severe eczema in an infant Five months old male baby with severe eczema since 2 weeks of age. Atopy on the mother's side. Otherwise history is unremarkable. Any thoughts on therapy? Because I have not been involved in the care of small children for many years, I consulted Dr. Susan Schuval, a very experienced Pediatric Allergist and a member of our AADMC Advisory Committee. Her response is enclosed below.
In a very young infant with severe eczema, I would think about immunodeficiency diseases (e.g. Wiskott-Aldrich, Job's Syndrome), food allergies (milk, soy), other dermatologic conditions (icthyosis), as well as atopic dermatitis. The treatment of atopic dermatitis is fairly standard and includes an adequate skin care regimen (infrequent bathing, frequent moisturizing, avoidance of soap and other irritants, antihistamines for the relief of pruritus (hydroxyzine or diphenhydramine), and topical corticosteroids (I would use low-medium potency on such a young infant - hydrocortisone, mometasone-ointments are preferable to creams for better penetration). Tacrolimus ointment may be helpful in the future but is currently approved only for age one year and above.
